CCP Chronic Disease Management & Care Coordination 3 — Questions and Answers
Question 1: A patient with COPD reports using their rescue inhaler more than twice per week. According to GINA/GOLD guidelines, this finding indicates:
- Adequate disease control requiring no change
- Poorly controlled disease requiring step-up therapy review (Correct answer)
- Overuse that warrants inhaler prescription cancellation
- Improvement compared to standard COPD progression
Correct answer: Poorly controlled disease requiring step-up therapy review
Rescue inhaler use more than twice per week is a recognized marker of poorly controlled COPD/asthma that triggers a therapy reassessment per GOLD guidelines.
Question 2: Which population health tool BEST helps care coordinators identify high-risk patients who may need proactive outreach?
- Patient satisfaction surveys
- Risk stratification algorithms using claims and clinical data (Correct answer)
- Annual wellness visit scheduling systems
- Referral management tracking software
Correct answer: Risk stratification algorithms using claims and clinical data
Risk stratification algorithms analyze claims, clinical, and social determinants data to identify high-risk patients before crisis events occur.
Question 3: When a care coordinator facilitates a transition from hospital to skilled nursing facility (SNF), which document is MOST critical to send at the time of transfer?
- Patient's insurance card copy
- Comprehensive medication reconciliation list (Correct answer)
- Primary care physician's CV
- Patient's full 10-year medical history
Correct answer: Comprehensive medication reconciliation list
A comprehensive, reconciled medication list at transfer prevents medication errors, which are the leading cause of adverse events during care transitions.
Question 4: The PDSA cycle used in chronic care quality improvement stands for:
- Plan, Delegate, Schedule, Assess
- Plan, Do, Study, Act (Correct answer)
- Prepare, Diagnose, Solve, Apply
- Prioritize, Define, Sustain, Advance
Correct answer: Plan, Do, Study, Act
The Plan-Do-Study-Act (PDSA) cycle is the standard rapid-cycle improvement methodology used in healthcare quality improvement initiatives.
Question 5: A patient with type 2 diabetes also has stage 3 chronic kidney disease (CKD). Which medication commonly used in diabetes management requires dose adjustment or avoidance in this patient?
- Insulin glargine
- Metformin (Correct answer)
- GLP-1 receptor agonists at standard doses
- Sulfonylureas only
Correct answer: Metformin
Metformin is contraindicated or requires dose reduction in CKD stage 3b and beyond due to risk of lactic acidosis from impaired renal clearance.
Question 6: Social determinants of health (SDOH) screening in chronic disease management is MOST important because:
- It fulfills ICD-10 coding requirements for reimbursement
- Unmet social needs like food insecurity and housing instability directly worsen chronic disease outcomes (Correct answer)
- It replaces the need for clinical assessment tools
- Only patients in rural areas have significant social needs
Correct answer: Unmet social needs like food insecurity and housing instability directly worsen chronic disease outcomes
Research consistently shows that SDOH such as food insecurity, housing instability, and transportation barriers are major drivers of poor chronic disease outcomes and health disparities.
Question 7: In a patient-centered medical home (PCMH), care coordination responsibilities are PRIMARILY held by:
- The insurance case manager
- The entire care team, including non-physician team members (Correct answer)
- The hospital discharge planner
- Specialist offices receiving referrals
Correct answer: The entire care team, including non-physician team members
PCMH models distribute care coordination responsibility across the entire interdisciplinary team, not solely to physicians or external case managers.
CCP Chronic Disease Management & Care Coordination 3
A patient with COPD reports using their rescue inhaler more than twice per week.
According to GINA/GOLD guidelines, this finding indicates: